Etiology

Breast cancer is the second most common cancer in women after skin cancer. Of breast cancer patients in 2008, according to the American Society of Plastic Surgery, approximately 80.000 women underwent breast reconstruction

Types of reconstruction

Immediate reconstruction may be contraindicated if radiation treatment is planned

Prosthetic reconstruction with a temporary tissue expander or a saline-filled implant placed behind the pectoral muscle

Autologous breast reconstruction - latissimus dorsi myocutaneous flap is muscle from the back with skin rotated to the anterior chest for the creation of breasts and often involves the use of a breast implant to create volume

Another option is a Transverse Rectus Abdominis Myocutaneous - TRAM flap - an ellipse of abdominal skin and subcutaneous tissue based on the rectus abdominus muscle. Blood supply is maintained with superior epigastric and inferior epigastric arteries

Nipple reconstruction is usually the last part to be completed and is considered necessary for the patient's psychological well-being. Traditionally performed once the reconstructed breast has settled in. Various techniques, from skin tattooing to reconstruction of the nipple using tissue from other areas of the body

Reconstruction of position, size, shape, and color of the native nipple-areola complex currently are attainable goals; functional restoration of erectile ability and erogenous sensation are goals for future reconstructive surgeons. It is vital to use the opposite nipple as a guide if present; if not, it is essential to mark when the is awake in a sitting position for optimal results

Complications related to poor blood supply can be prevented by creating a nipple that is 20-30% larger than the contralateral nipple if applicable

Preoperative Considerations

Patient Population

Mostly female 30-70 years

Associated Conditions

Breast cancer, cardiovascular disease, post-chemotherapy (know what drugs and last treatment), pulmonary disease

Position

Supine

• May need to temporarily change to sitting for evaluations during the reconstruction

Keep the head in a neutral position

Massage/reposition the head during lengthy procedures to prevent alopecia

Heels off mattress for more prolonged procedures

Padding

Protect pressure points. Arms either with hands supinated <90degree (prevent Brachial Plexus injury from stretch) or alongside with hands facing body. Pad to prevent ulnar nerve injury. Possible pillow under knees if hx of back pain, maintain the lordotic curve in the spine, and avoid tension on the sciatic nerve.  Prevent alopecia with padding of the head.

Check eyes - always tape them to prevent corneal abrasion

Monitors

Pulse ox, ECG, NIBP, temp, Bair hugger (lower), PNS if muscle relaxant

Incision

Depending on the technique employed

Surgical Time

1-2 hrs

Preoperative Area

Verify NPO, consent signed, questions answered

If any chemotherapy history, try to find out about drugs

• Bleomycin - pneumonitis, pulmonary fibrosis
• Cisplatin - renal failure
• Cyclophosphamide - plasma cholinesterase inhibition, hemorrhagic cystitis, acute delirium
• Doxorubicin - cardiomyopathy
• Methotrexate - renal failure, irreversible dementia
• Vincristine - peripheral and autonomic neuropathy

Antibiotics

Per surgeon

Physiologic Changes

Decreased FRC and HR

Increased venous return, leading to increased preload and CO

Increased intraabdominal pressure

Zone 3 (a-v-A) in the dorsal portion of the lungs

CNS

Blood/cerebrospinal fluid drainage is gravity dependent, valve less; when supine = increased ICP, which decreases cerebral perfusion pressure (CPP= MAP-ICP/or CVP).

If BMI is elevated - decreased FRC. Difficulty maintaining tidal volumes due to body weight pressing down on the chest

Postoperative Complications

Partial and total loss of nipple

Epidermolysis (development of blisters in the skin)

Loss of nipple projection

Discoloration

Anesthesia

General with ETT if muscle relaxation is needed

Induction

Preoxygenation

Lidocaine 1 mg/kg/IV

Propofol 1-2 mg/kg/IV - consider etomidate 0.1-0.4 mg/kg/IV if cardiac disease - note myoclonus and adrenocortical suppression

Fentanyl 1-3 mcg/kg/IV

Succinylcholine 0.5-1.5 mg/kg/IV

Maintenance

Isoflurane - if smoker use sevoflurane

Fentanyl

If a muscle relaxant is needed, consider atracurium 0.3-0.5 mg/kg/IV

• Not for asthma pts (histamine release)

Emergence

Zofran IV

Neostigmine and glycopyrrolate for reversal if use of muscle relaxant

Anesthetic Considerations

Maintain blood pressure to avoid a decrease in blood supply to the nipple

Possible chemotherapy drug implications